Q: Hi Shawn. As a psychologist myself, I’m wrestling with whether to work with an increasing number of patients asking me to accept reduced fees. With the bad economy, more people want sliding-scale services. The problem is that the more sliding-scale work I do, the more hours I have to put in to pay the bills. It’s tiring. Just wondering how you approach the problem. – Michelle
Dear Dr. Michelle,
For those unfamiliar with the term, a sliding-scale fee structure is a variable rate based on a person’s ability to pay for a product or service. People of means pay the full fee, while those with financial difficulties pay less for the same service. While I think they’re nice in theory, sliding scales come with some hefty trade-offs for both therapist and client.
You and I know, Michelle, that we psychologists hate to talk about money. It is one of the only consistently taboo subjects in therapy. While we welcome the most ghastly details of life, we avoid this topic like a politician avoids the confession booth.
In a 1996 study (an old study but one of the most recent since we avoid discussions of money even in our own professional literature) Catherine Keuffel found that we shrinks avoid the topic of payment because we tie it to our own insecurities. Those fears include potential conflict with the client, questions of self-worth, uncertainties about the definition of the service we provide, and other bits of neuroticism. I’ll admit to some anxiety about posting this essay for fear of looking like the Grinch.
Our reticence on the matter is just plain wimpy since we ask our clients to face their own insecurities. So in the spirit of chipping away at a needless taboo I’ll share my opinion on sliding scales. I hope you don’t mind a cold and unsentimental discussion that runs contrary to our therapy training.
Psychologists are taught that it is our moral responsibility to work for little or nothing at least part of the time. The APA’s code of ethics instructs psychologist to “strive to contribute a portion of their professional time for little or no compensation or personal advantage.”
Unfortunately, the APA doesn’t explain who should pay the costs associated with treatment, how to monitor the effects of charity, or how to implement a fair fee structure. Being well-intentioned people, they probably assume that their call to altruism needs no explanation, but actions of the heart can have unintended consequences. While sliding scales can feel good – and in fact they may be good – they can also be philosophically and pragmatically troublesome.
Psychologists who offer sliding scales should be perfectly clear with themselves and with their clients about who is paying for what. As is often the case with charitable acts, some unknowing third party can end up paying the bill. Worse still, charity sometimes achieves undesired ends.
Here are some reasons that psychologists should think carefully about sliding scales:
Sliding scales create a potential moral hazard.
Minimal or no payment insulates a client from the risk of losing his or her monetary investment. Clients who don’t pay are therefore less likely to treat the service respectfully or work hard for their desired outcome. People simply tend to devalue things for which they bear little responsibility. That is obviously not true for everyone, but it is true for humans in general.
Consider the manner in which people treat rental cars. I’ll admit that I’m a little less concerned about speed bumps when I’m driving a rental, and I’ve never changed the oil in a rented engine. Why should I? I have a negligible investment in the vehicle.
I believe that reduced fees should be reserved for people who are somehow invested in treatment. I realize that a minimal payment can represent a significant monetary investment for someone with limited resources. The point is that investment in some form or another is necessary for good outcomes. The absence of investment is a recipe for resentment and wasted time.
I know whereof I speak, having worked in a prison where services are provided at no charge to the recipient. As you might imagine, those free services are treated with the respect befitting a rented Yugo while taxpayers foot the bill. Therein lies the moral hazard, which brings brings me to my next point:
Sliding scales can force one client unknowingly to subsidize another.
As you pointed out, Michelle, we psychologists must pay our bills. We have a finite number of hours in which to generate enough income to do so, and we don’t typically make a lot of money. If a psychologist charges someone a fee that is insufficient to cover the bills for that portion of time, then she must recover that loss from someone else.
This is where altruism and good intentions get complicated. It may feel good to donate services to a particular client, but the psychologist who does so may be overcharging others in order to pay for that charity. It can hardly be called altruistic to donate someone else’s money.
One clinic I’m aware of openly states that a certain percentage of payment from full-fee clients is used to subsidize reduced-fee clients. That seems a perfectly reasonable and ethical approach. The clinic is acknowledging that their prices are higher than they would be otherwise, and they are giving their full-fee clients the option of participating in a charitable act. Those clients can choose a different clinic if they wish to avoid the added expense.
Sliding scales turn psychologists into social engineers.
Sliding scales force a psychologist to decide who is worthy of special treatment, and who is unworthy. In private practice, where a clinician typically has no objective method of determining “worthiness,” the decision must ultimately rest on sloppy, emotional impulses: This person deserves it; that person does not. Ick.
To complicate things, the psychologist cannot be sure that the recipient of charity is the most deserving. I’ve seen cases in which relatively wealthy individuals finagle a reduced fee while everyone else pays the full fee.
To prevent that problem, some clinics devise semi-objective, progressive fee scales based on documentation of income. That is more consistent than gut impulse, but as a private practitioner I’m not about to begin tracking the income of my clients, nor am I willing to dabble in the ugly business of devising charts and fee scales that remain subjective at their core.
One of the reasons I will never run for public office is that I have no stomach for the partiality and nepotism that comes with it. I want no part of deciding who is worthy of special favors and who must suffer to pay for those favors. The very idea is repellant because it invariably involves stealing one person’s dignity and another person’s resources.
Does that mean that I oppose charity? Absolutely not. I’ll return to that topic shortly.
Sliding scales punish those who are willing to pay for the psychologist’s expertise and time, and they reward those who are unwilling to pay.
I realize this isn’t the intent of sliding scales, but it is on one of the effects, and it is the worst business model I’ve ever heard of. Other industries offer sliding scales, but I can’t think of any profession that supplicates itself like mental health professionals do. I can’t recall the last time a grocer, a plumber, or an accountant offered to take less money out of the goodness of his heart.
That’s not to say that their hearts aren’t good, but they may be operating under different assumptions. They may assume, for example, that catering to people who are unwilling to remunerate them would kill their business.
So how do we psychologists offer so much sliding-scale work and manage to stay afloat? We work longer hours and see extra patients. But that, too, can come with unintended costs paid by unconsenting others, which brings me to my next two points…
Sliding scales can force a clinician to work longer hours, which may reduce his or her effectiveness.
Psychology is tiring work, and psychologists are prone to burnout. Any clinician who works extra hours in order to offer reduced fees should, in my opinion, ensure that her clinical effectiveness does not suffer. Reduced effectiveness is essentially another subsidy paid by unconsenting clients who are paying the full fee and deserve our best performance.
Sliding scales can force the psychologist’s loved ones to subsidize treatment.
Because reduced-fee services can require longer hours, there may be less time and fewer emotional resources available to other important people in the psychologist’s life. Any psychologist with a sliding scale should ensure that his fee policy isn’t exacting added costs on loved ones who never agreed to the payment policy.
Having said all that, I think sliding scales are a fine idea. I am very aware that some financially strapped people are better served by private-practice psychologists than overwhelmed, underfunded clinics. And at the risk of sounding defensive, I have donated literally thousands of hours of my time to charitable causes.
But any psychologist who offers a sliding scale should guard against unintended consequences. Since you are searching for objective guidelines, Michelle, I think that sliding scales should meet the following criteria:
- The time and expertise that we donate must be our charitable contribution alone. We should not force clients to subsidize one another by way of money or reduced effectiveness.
- We should be mindful of the potential moral hazard inherent to sliding scales, and we should address the problem immediately if outcomes are in jeopardy.
- Our fee structure should not cause us to neglect loved ones or other important obligations.
- We should be be able to justify, if only to ourselves, our method of determining charitable worthiness.
As the APA demonstrates with its vague call to altruism, it is easy to submit to emotional sentiment, outcomes be damned. But of all people, we psychologists should obey two principles: that emotions shouldn’t rule behavior, and that forethought can prevent unwanted and unintended consequences.
-IS
References
Keuffel, C.R. (1996). The money metaphor: Therapists’ experience with fee transactions with their clients. Dissertation Abstracts International: Section B: The Sciences and Engineering, 57(5-B), 3413.
Hello Shawn,
I am glad someone is addressing this White Elephant. In the first few years after I opened a private practice, I offered a sliding fee scale. I have since decided it is not the best practice. I volunteer in a couple different ways, but having a sliding fee scale and then trying to justify it and track people’s income – adjusting it frequently, can take precious time from their other life issues. Or, allowing someone to pay $20/hour for a year because they don’t mention they got a full-time job, or I don’t ask, is just a type of avoidance (not the best approach to take to face life’s difficulties). I have since developed a more straight-forward and business-like approach to working with people to facilitate (working together) to develop/create better lives for themselves.
I have started a new way to help people in great need, when part of it is financial. I now offer, for only one client at a time, the opportunity to get an hour of service from me for $10 plus one hour of their volunteer work in the community (with signed attendance slips). I believe this will have several benefits.
And, I am wondering if other psychologists might want to try this “new fee schedule” and meet once in a while to support each other and track its effectiveness.
Keep up the good work, and thank you for the clear thinking around sliding fee schedules.
Hi TJ, that’s a really creative idea. Another colleague pointed out (and I should have included it in the blog entry) that there are other ways to maximize treatment without lowering fees, such as meeting less frequently and giving extra homework to capitalize on time between sessions.
TJ and Shawn, what excellent ideas. Food for thought.
Ha ha.
My fee was standard and unmodifiable (although I also do insurance work), so I mean my own fee, until the economy changed. Now, i see that I must negotiate with some people or they simply won’t be able to afford the help they need. I don’t worry too much @ how to determine the exact amount as I know that, eventually, in therapy, their general financial situation will emerge. So, if they have finagled me into a lower fee than should be, it will be revealed. I actually feel pretty trusting of people in this regard.
We ARE the lowest paid professionals in the health care field; my dental hygienist earns more than I do, for example. I have written in my blog a bit about the therapist’s point of view. While insurance companies have kept our wage insultingly low, the other part is that people generally don’t understand how a practice is set up. For example, they might see a therapist charging $100. a session and multiply that by 40 hours per week
Well, if only we could stand up to that… I find my clients currently are more stressed than ever and I am able to do a good, solid job with fewer. 20 per week would be my absolute maximum and, honestly, I am better working much less than that.
Bottom line: Can’t be in this job for the money
Hi Paula. Thanks for pointing out just how limited our schedules are. Regarding insurance, yes they have played a part in keeping our fees low and they would do well to use us more to prevent many physical ailments. But I think WE play the biggest role in keeping our fees low. If we weren’t such wimps about money, we’d do better. I believe US psychologists’ median income is about $60k. That is pretty skimpy in light of the training, the liability, the business costs, and the student loans that most of us incur. What is your blog address?
Shawn, my blog is called A Therapist’s Thoughts and the address is, http://www.therapiststhoughts.blogspot.com Thanks for asking! Currently, at the top of the landing page is a post about how to be open (as a patient) in the therapy session, rather than going in with defenses in full gear.
TJ, I really like your idea about offering one person on-going therapy for a nominal fee + verified volunteer time. I think I am going to do this too. One question: How did you arrive at the 1 hour requirement? In other words, why not $10.oo + 4 hours per week volunteer work?
Hi Paula, TJ & Shawn, I really appreciate this discussion. I come from a business background, two decades in magazine publishing & marketing, and I find other therapists shy or uncomfortable when I try to discuss the financial aspects of the therapist/client relationship. I’ve actually had to learn how to soften my approach with clients, as talking about money is not difficult for me. I’ve had a few clients balk when I remind them about the missed apptmt fee and others walk when I decline to offer a sliding scale. I have a hard time with the fact that clients seem so comfortable asking us to lower our fees, and seem ready to bargain shop if they can’t get us to agree. I guess there are enough other therapists out there that will agree. I don’t offer sliding scale fees, and am fairly comfortable saying no to requests. On occasion, when a client who has been seeing me for awhile undergoes a financial challenge (loses a job, etc.) I will offer a temporary reduction in cost. I do accept some insurance, but that was always part of my plan when I went into this business. TJ, I like your suggestion about tying it to some volunteer work and I might try this in the future. Appreciate the opportunity to vent about this subject.
Thanks for weighing in, Chris. Good to hear from you.
It’s bad for everyone when therapist’s fees are kept too low. I have recently become aware of some therapists pandering to “the one who writes the check”, in couples counseling, for example.
None of us should ever have to be that desperate. But, it happens.
If the business part of the therapy arrangement is addressed efficiently and fairly, the therapist will be free to do ethical, appropriate work.
Hi All,
I rarely get time to read blog entries but I must say I really appreciate your writing and also the thoughtful discussion afterward.
I like that the maximum 20 direct client contact hour was mentioned. And for me and many therapists I know this is truly a max, with work being better somewhere between 12-17. However that is still a full time job when you have to schedule in time between sessions, emails, phone calls, progress notes, supervision, case consultation with peers, training – gotta get those CEUs in etc. And I don’t think clients really do ‘get’ that unpaid part.
That all being said, here are my thoughts on sliding scale, and on some things already said…
-I do offer sliding scale, usually one client out of all that I’m seeing
-I set the minimum that the sliding scale fee goes down to at a number I can HONESTLY live with. If the standard fee here is $150/hr and my sliding scale goes down to $95/hr, that is still a break, and that may be the lowest I can go to still keep the rest of my work in check (to avoid having to take on more clients to off-set, and also to just avoid resentment which would definitely not help my client)
-I offer this to the client for a SET NUMBER OF SESSIONS. Usually this is 12 sessions. I’m not a fan of brief therapy, ie 6-8 sessions, but I do think by 12 a lot can change and this also gives them 3 months to plan ahead in case they’ll want moreie full fee. Additionally after 12 sessions, and often sooner, they can usually decrease frequency so as to minimize monthly impact on their budget.
-I set up a contract with them to set out the terms of our sliding scale arrangement. I expect reasonable compliance ie showing up for sessions, giving proper cancellation notice, paying their portion, doing most of agreed upon homework etc. I say that we will evaluate how things are going every 4 sessions, and then carry on if said agreement is being met
-I advise them ahead of time when their sliding scale sessions are running out, say when they have 2-3 left to help them to plan for that. I also remind them that these are limited to allow space for others that need sliding scale fees. Most clients show fondness towards this idea, as they can allow others to receive the leg up they once needed.
Personally I disagree with the ideas others had of community service or volunteer hours. To me that is totally unrelated to the work we are doing, and seems to infringe upon their rights to choose what they do with the rest of their lives. A bit like dangling a carrot if you ask me. Think of how others could take this further, like one said, instead of one hour, how bout 4? Instead of community service, why not go to a church service each week. I mean, we really can’t expect/demand these kinds of things from our clients. Particularly in my work. I have stressed couples on the verge of divorce trying to manage two jobs and raising kids. I can’t even dream of asking them to each add an hour of community service to that, let alone just finding a place and getting that set up! Or my agorophobic clients…hmm, that would be tough. Or what about the severely depressed who can barely make it to work each day? They are usually at their breaking points when they are ready to seek help, just starting to work on themselves is usually a stretch for them. This volunteer business should only be if it comes from within them, in my *humble? opinion.
One final thought…I believe that there are a lot of mediocre therapists that aren’t making money, not because of the economy or insurance companies but just because they aren’t really that good. Maybe they should accept lower fees from clients, not because they feel bad for the people or because of the economy, but just because that’s really what they are worth? Let’s face it, there are probably a lot of shrinks in the US & worldwide that haven’t had to touch their fees in spite of the economy or insurance rates of pay.
Okay Shawn, I’m definitely coming out more the scrooge in this than you
But hope there’s something to further stimulate the discussion this important, but often confusion producing, topic.
Hi Jennifer, I don’t think you came off as Scrooge-like but simply pragmatic. You make a good case against TJ’s suggestion of having people do community service in lieu of payment. I still think it’s an acceptable idea (though I personally wouldn’t do it), but you point out the slippery-slope danger of therapist imposing their values on the client. I happen to know TJ and I know that he wouldn’t do that, but I wouldn’t put it past other therapists I’ve met.
Hi Jennifer. I think you have been innovative and created an idea that works for you and gives some help to people seeking therapy. 3 months is better than nothing.
I’ve been working on a way to shift my practice balance to more private pay and fewer insurance paid cases as I find that the dealings with some insurance companies are just oppressive.
I have a post up on my blog now re. the choice to self-pay for therapy, trying to educate the public on what the effect is on them when they do use insurance—basically they trade their privacy for the reduced cost.
I would love to see some version of the second paragraph of your comment on my blog sometime if you are ever so inclined.
I think there is a real absence of understanding by most potential and even on-going clients of what it takes to become qualified to be in practice and what it takes to maintain the license.
Paula,
My sincerest apologies for the late reply. I have had good intentions, including going to your blog, but life is so full. I have 3 kids still at home (15, 8 and 2!), a busy practice and am doing some wonderful, but intense, LGBT advocacy work here in Calgary, particularly aimed at engaging people of faith. That all said, I do seem to manage to connect on Twitter so if you’re there, I’m @jennwatts Blessings!!
Commenting on part of what Chris wrote: The “bargain shopping” seems really problematic to me. One therapist cannot replace another. This is somewhat true of other types of healthcare providers but especially so with a therapist. This is such a personal choice! I believe the research results which say that the quality of the therapy relationship is essential to the outcome of the therapy. I have to wonder where our professional associations are when it comes to educating the public. Someone new to therapy really may not think about how many things there are to consider when making this choice, besides price!
Hi Paula, in my somewhat jaded and cynical opinion, our professional organizations are busy obsessing over climate change (which they know nothing about), “social justice” (what the hell is that, and what does it have to do with treatment of mental disorders?) and diversity (which serves to make them look good but doesn’t really accomplish anything). I dropped my support for the APA and was very clear with them why I was doing so, and what it would take for them to earn my dollars again.
I am reading through this thread as I prepare to open my own practice. The whole sliding scale fee discussion is helpful, but your comment on March 1 re the APA just made me HAPPY.
Thanks Tricia. I wonder how many people share the sentiments but just don’t speak up about it.
This is a great discussion.
My dentist refused to lower his fee dispite a year of great financial hardship on our part. He has his own b ills to pay. I was not pleased, given a 20 year relationship but I still go to him.
I do not subscribe to requirong people to volunteer in order to get a reduced fee. It aasumes that those with less money have more time, which if we think of our own situation we know isn’t necessarily so.
Havimg a fee we will not go below is important and a decision I made that I violated and then resented. I also let a semi retired well paid professional talk me down below what I should be charging him, given that he owns a vacation house and takes expensive trips. I am not sure how to discuss his apparent lack of investment in his therapy on top of a deep narsassistic wound.
One more thing… According to some regulatory body, the name of which I can’t remember, it is against the law to charge different people different fees. There needs to be guidelines for your decisions and indicated on your bill that you are forgiving some of the fee.
THanks for this discussion. I am rethinking how I handle requests for reduced fees.
Thanks, Beth. I had a similar experience when I agreed to lower my fee for someone who was clearly much better off than myself. That breeds resentment, and it’s another reason to think long and hard about lowering fees.
The client/patient/whatever weighs in.
Kudos for talking about fees. It doesn’t surprise me to learn this is a taboo subject. Here’s my two cents. ;->
Is the service you provide worth the price you charge? That’s it. There’s nothing special or sacred about what you offer. You are selling something in the marketplace. The determination of value can only be made by the buyer. It helps if you truly believe, with good reason, that your service is worth the price that you put on it. You are fooling yourself if you think your clients don’t understand or appreciate your underlying expense. The niceness (read expense) of a therapist’s office is the first thing a client sees. And the diplomas are typically on prominent display. All businesses require expenditures. It’s a given.
Back to the question. Here’s a comparison – sort of. As a musician who hasn’t been able to quite figure it all out on my own, I have tried lessons. The going rate is currently somewhere between $35-$50 an hour. I go in hoping for two things; the person knows something, and they are able to convey that something to me. Alternatively, music instruction books are getting better and better all the time. The last one I bought cost $20 for 70 pages of instruction and musical examples, accompanied by a CD with a band backing up the tracks. That’s stiff competition.
From my end, I think anyone in the helping trades should constantly be thinking about how much they charge, with the aim of doing everything possible to invest their service with value sufficient to warrant the charge. Anything remotely resembling, “That’s my fee, take it or leave it” (admittedly exaggerated) is doing your clients and yourself a grave disservice.
The fact that the insurance industry insultingly undervalues your services is “a whole nuther”, as the kids say. They undervalue everything. That’s what they do. That’s why they’re rich and the rest of us are bitching about money.
Well said, Kirk.
I have many comments to make, so I hope all of you will bear with me…as the devils advocate.
In my experience, dentists, grocers, plumbers and many other professionals are willing and accustomed to negotiating fees. My dentist does give me a reduced fee based on my income (implants are very expensive.) I get deals from doing repeat business with farmers that sell at my local farmers market. The regular grocery store is rife with coupons and specials. My first therapist, whose fee was 150.00, put me on a sliding scale, charging me 80.00 per session. I could go on, but I think those examples suffice.
Insurance: I am an in-network provider for BC/BS and they pay about 65.00 per session, which includes the client co-pay. I don’t mean to be a naysayer here, but there’s something very wrong in not considering that the therapy fee is different for client’s, those with insurance and those paying out of pocket. Of course, this only creates a dilemma for therapists that accept insurance, however, it does have some bearing on therapy fees in general. It’s clearly unfair to client’s that pay out-of-pocket. No easy answers here and a too far reaching and involved subject to entertain in this thread.
Are therapy fees arbitrary? Who came up with the standard fee schedule (90-150, generally)? How and when is it adjusted?
I doubt there’s a perfect and non-subjective answer to these questions, or none that I can find. Nevertheless, a therapist with 12 client’s per week, charging 100.00 per session makes 4,800.00 per month or 57, 600.00 per year. On that income, the average individual is neither getting rich nor in the poorhouse. 57K is on par with what many full-time, agency positions pay minus the health coverage and plus much more free time. It’s not, paperwork, client melt downs, etc. included, a full-time job, as it relates to hours worked.
Does experience count for anything? Does the therapist with 20 years experience deserve a higher fee than the therapist who has 5 years experience? Based on my MA cohort, experience as a therapist has very little to do with the fee. Many in my cohort went right to 150.00 as soon as they opened a private practice. I’m not making any judgements regarding whether or not they are deserving of the fee, considering the time and expense of getting the education (the price of an MA varies widely), I’m just questioning if actual time spent in a therapeutic role has or should have any bearing on the fee schedule?
The truly bad therapist will have difficulty making a good living in private practice and a very good therapist might have similar difficulties. Being a good, mediocre or a bad therapist seems to have very little to do with fee schedules. The nature of the work lends itself to a lot of subjectivity.
The questions remains: What formula was used when coming up with the general, per session fee? To whom was the question addressed? Whom did “they” have in mind when setting the general fee? Does the latter have anything to do with the socio-economic standing of the client and the therapist? For me this last question is important…the question of accessibility is no less important than if applied to medical and dental care.
I can remember bringing up these questions in my MA program and being chided for deigning to ask such questions. It is a taboo subject. I think most people, particularly those part of a professional group, are very likely to side on their own behalf and I don’t think our profession is any different. It’s just that the nature of the therapy business and it’s supposed tenants make it appear that we SHOULD be different. I relatively sure that most of us are aware of the “should’s” and grapple with what part of “should” is fair enough and what parts, based on our individual circumstances and beliefs (etc.), are problematic.
I do have a sliding scale; does it get me into trouble at times–yes, it does. Is there an arbitrariness to it–yes, there is. Is it always fair, per my criteria–no it’s not. Can I always tell if a clients is really in financial need or if they feel they are in financial need–no, I can’t. Is the answer to simply have one fee for every client…not for this therapist because it does not reflect the underpinnings of a capitalist structure, which is by it’s very nature regarding pricing, often arbitrary. I would vote for a single-payer system and in my profession I would accept a fee schedule aligned (via taxation in both directions) with a single-payer system. I would rather not grapple with setting fees and wished they were the same across the board and that they were based on something less than arbitrary. As I see it, the deeper question has to do with fairness and that’s a complicated equation to solve, especially for a culture built on a Capitalistic ideal.
I don’t believe that charging a higher fee makes a client value the work more or that they will take the work more seriously. A client making a lot of money may or may not value his or her dollar more or less and the same is true for a client with less money. It’s way too subjective for a single answer to be even close to true. I think this is one of those arguments that made of behalf of the therapist and as such, it’s no more than a justification for charging a higher fee. It’s tantamount to concocting and applying a paradoxical intervention before the therapist has even met the client.
Hi West,
You wrote, ” I think this is one of those arguments that made of behalf of the therapist and as such, it’s no more than a justification for charging a higher fee.”
Actually, I believe I made the point that a set fee allows for a lower fee.
I appreciate your thoughts, though I suspect you and I have some fundamental differences in our idea of fairness. One of the things that troubles me about the direction our society is taking — in which the word “fairness” is tossed about rather recklessly — is that considerations of fairness only go in one direction.
For example, discussions of “fairness” in government employee compensation tend only to consider what’s fair for those employees. What about fairness to the taxpayer, many of whom are barely getting by? They get no say in what’s fair. They must pay up or be punished. The taxpayer’s half of the discussion is routinely dropped. Where’s the fairness in that? (And here’s the unintended outcome: most government employees now enjoy a higher standard of living than those of us who are paying for that standard of living. That’s because they get to define the terms of “fairness.”)
In this case, I feel it is my duty to NOT be the arbitrator of fairness because it similarly forces one person to pay for another. I have no interest in being an agent of arbitrary income transfer.
The beautiful thing about an open market, West, is that you can choose to offer a sliding scale, while another clinician can choose not to. Potential clients, in turn, get to choose the clinician they prefer. Under the single payer system you advocate, those options disappear. Everyone waits in the same line, and the “single payer” dictates the terms of service. Like an Army mess hall, everyone gets the same thing, regardless of skill, fit, or appropriateness of treatment.
I see the equality in that, but I don’t see the fairness. I’d rather you and I have the freedom to decide independently how to seek compensation, and our clients can choose independently which one of us they would prefer to work with. Everybody has options, and everybody can win.
I may have missed this, but what I think a lot of people don’t truly understand is that when using insurance they have access to diagnoses etc. Even as a therapist I would much rather pay out of pocket and not have to carry a particular stigma with me if it could be avoided. Once those types of diagnoses make it into your insurance records we all know there is no telling what the insurance may do. If you have to switch insurance because of layoff or change of jobs, or just simply (even though it’s not legal; we all know they do it) raise your insurance because you have become more of a liability. Insurance is great, but I would never recommend it to anyone for mental health, simply for that.
But one would be lying if we didn’t say that it would be nice to have less paperwork and more money.
One of the main reasons I don’t work with insurance is the diagnosis issue. Once it’s there, it might be there forever.
Exactly! Most people don’t understand that and it’s kind of hard to inform them.
OK, I just can’t resist another two cents. What the hell, talk is cheap.
Mitchell said, “it’s kind of hard to inform them.” What do you mean, morally hard? As in, “You can pay me $125 and we’ll keep everything just between the two of us, or you can pay me a $25 copay, the insurance will kick in $40-$50, and your psychological details will be painted in easily readable neon colors for the rest of your life.” Yeah, I can see how that might be awkward.
Unfortunately, the value set by the insurance industry is the real market price for most clients. That’s my unsubstantiated guess, anyway. Shawn doesn’t accept insurance. How common is that in the business?
West said, “Whom did ‘they’ have in mind when setting the general fee? Does the latter have anything to do with the socio-economic standing of the client and the therapist?” It has everything to do with this. The euphemistic phrase ‘out of pocket’ always amuses me. Let’s talk comps for $125-$150. A round of golf at an upper SES club. A massage at the same club. So now we are in discretionary income territory. As long as you are ok seeing ‘that kind of person’, no problem. As one who has had life-long issues with procuring and sustaining a decent income, my pocket cannot afford the luxury of psych services. As long as we’re getting personal (hell, it’s just the Internet) the last person who wanted $125 for her services suggested I “go out and get a job” that payed just enough to cover her weekly fee. I am reminded of a certain movie from the 1970s wherein the characters wore long, purple, fur coats with matching hats. But I digress.
I think the psychological services have a built in moral dilemma, or at least a conflict of interest. In days of yore, care of the soul was left to priests and the like. They were usually getting their daily bread from other sources. Today’s psychologist wants to save souls, AND have a nice home, office, car, and maybe play an occasional round of golf at an upscale club. How’s that workin’ out for ya?
OK, so that was three cents. So sue me. Ooops, another taboo.
Clearly I am doing something wrong. I am not living the rich and creamy lifestyle to which some of you are alluding.
That was a great run lol. I agree with you, I didn’t get into it for the money. I also have to pay my dues and earn my rights ya know. But I won’t go broke doing it. It’s what I love but if I can’t live by it then it’s not right